Live Discussion with Dr Dimitri Gavriloff - 13th March 2019

Dr Gavriloff will be hosting a live online discussion here on Wednesday 13th March, from 7:30pm to 9:00pm British Time or 2:30pm to 4:00pm US Eastern Time.

He will discuss as many topics as possible in the hour and a half and, as always, you are welcome to ask any questions at all about sleep or the Sleepio program. If there are a lot of questions, he may not be able to answer all in the time available, but will try to answer as many as he can.

Please do note that, as per our guidelines, Dr Gavriloff will not be able to give personal medical advice including those about medication. His replies to questions will be made in such a way as to help as many people as possible who might have similar issues.

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Posted 8 Mar 2019 at 3:31 PM
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  • Sleepio Member

    • 4 comments
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    Session 4

    I just did Session 2. I know that if I have an important day ahead of me in my job, or even a holiday where I will be travelling, then I have a tendency to put pressure on myself to get a good sleep, which is a recipe for having a bad sleep that night. The problem is, when I pressurise myself to have a good sleep it's hard to stop myself doing it – it often affects me physically, and it's at the back of my mind so it can be difficult to catch it and challenge the thought. Or sometimes it feels like challenging the thought doesn't work, because the anxiety is affecting me physically.

    It's just really frustrating. Any suggestions about how to stop this anxiety would be helpful.

  • Sleepio Member

    • 1 comments
    • 2 helped
    Session 2

    It seems that no matter how long I sleep each night I do not get restorative sleep. I never feel refreshed and ready for the day when I wake up. In the last week my average sleep stats were as follows:

    Awake: 12.4% (of total time in bed)
    REM: 18.5% (of total time asleep)
    Light: 59.2% (of total time asleep)
    Deep: 9.9% (of total time asleep)

    What can I do to get more restorative sleep?

  • Sleepio Member

    • 6 comments
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    Graduate

    The 15 minute rule is the most challenging to follow, I find that I just don't want to get up after 15 minute- it is cold and don't want to get out of the comfort of my bed and blankets that keep me warm. Also, this is the one thing I feel very stressed about when going to sleep, wondering how am I going to get out of bed when I am so much more comfortable in my bed . . . and to be honest, I just don't get up out of the bed after the 15 minutes . . . Any suggestions?

  • Sleepio Member

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    Graduate

    Can you clarify the suggestion about natural daylight? I believe we are to get natural daylight in the early part of the day, to reset our body clock. Does this mean being outside, driving in a car, opening the curtains, etc? I would think that outdoor exercise in the early part of the day would be ideal, but it may not always be practical.

  • Sleepio Member

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    in reply to Sleepio Member
    Graduate

    Hi granite bay, I used to get terrible foot cramps at night, until I started drinking Sole water first thing in the morning. You can google how to make it (it's made with pink Himalayan salt), but it helps with your electrolytes. I haven't had a problem since I've started drinking one teaspoon of sole water in a glass of water. Hope that helps!

  • Sleepio Member

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    in reply to Sleepio Member
    Graduate

    Hi Granite bay,
    Ouch! Those cramps can be so painful! Magnesium may help. lack of magnesium is the hidden reason why most people get foot cramps. Google offers up lots of information about it.

  • Sleepio Member

    • 10 comments
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    Graduate

    I have been diagnosed with Generalised Anxiety Disorder and Depression. I had been on medication until about 4 months ago. I had been doing very well, despite the insomnia. I got 4 days into the sleep restriction and ended up having massively increased anxiety, and I burst into tears on the Tube. I was getting back into some really bad mental habits.
    My Therapist (and my wife) think I should stop and take some time to take care of myself. Do you agree?
    I wonder if insomnia when caused by underlying mental health issues such as GAD might not respond well to the kind of brutal sleep restriction done here? I also wonder if SR would even work, as my anxiety is strong enough to keep me awake regardless of my sleep drive!

  • Sleepio Member

    • 129 comments
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    Expert

    Good evening everyone and welcome to this week’s live session. I’m Dr Dimitri Gavriloff, a clinical psychologist with a special interest in sleep and I work in both clinical practice and research. I’m here to answer as many questions as I can over the next hour and a half and will aim to make my answers as helpful as possible to the community in general.

  • Sleepio Member

    • 10 comments
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    in reply to Sleepio Member
    Graduate

    Hi – do you have any thoughts on my question above?

  • Sleepio Member

    • 129 comments
    • 46 helped
    in reply to Sleepio Member
    Expert

    Hi Granite Bay,

    Thanks for the question. People do sometimes report getting leg cramps when they wake and it can sometimes impact on people's nightly sleep too. The most sensible piece of advice I can offer here is to book an appointment to discuss this further with your doctor if you are concerned about them.

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    Hi Bluebell2,

    Thanks for the comment. I'm really sorry to hear things are tough. I notice that you're a graduate – did you find that things improved during the programme at all? If so, remember that you can always go back to the techniques that you've got in the library and use them again. It's tricky to give much more concrete advice without knowing a little more about your situation.

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    HI Zita,

    Thanks for the question. I can certainly empathise with how difficult the first week of sleep restriction can be, it's a truly tricky time for most people and is undoubtedly the most challenging part of the programme. The people I see in clinic also report the same thing too and so you're not alone.

    There are several things that might be helpful to remember when it comes to sleep restriction, however. The first is that quite often people experience a really tricky time in the first week or so of sleep restriction. For some, their sleep might seem particularly bad and it might even feel as if it's making things worse. This is generally because people who report poor sleep often have quite inconsistent sleep patterns and so it takes a few days to get used to the new consistency and work things through. The second point is that we only include sleep restriction as part of the treatment because it's been found time and again in robust clinical trials to be one of the strongest treatments that we have for insomnia. The third point is that “sleep” restriction is, at least to some degree, bit of a misnomer. That's because we're principally trying to restrict excessive time in bed, rather than principally sleep deprive people. This is the reason why we titrate the sleep window (adjust it) based on an average total sleep time from the sleep diary. Of course, you will lose a little bit of sleep initially, but this only serves to increase the sleep pressure that eventually helps with quick sleep onset and maintenance. If you feel like you would get longer periods of satisfying, unbroken sleep outside of the sleep window then you are, of course, welcome to try this.

    If you're currently spending 5.5 hours asleep in a 6 hour window then you're doing brilliantly and the window will increase as you go to meet you sleep need. It is, of course, difficult initially but if you stick to it, the evidence suggest that your sleep will improve. The challenge is to stick with it through the initial difficult period. If you've had poor sleep for a while, it might be worth considering whether the cost of a few weeks of less sleep might be worth a future of better sleep.

    Hope that helps a bit and keep up the great work.

  • Sleepio Member

    • 50 comments
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    Graduate

    It's taken 5 challenging weeks to finally get an increase in my SE. Yay! Now with the time change I'm slipping some. I was hoping to finally turn a corner and be awarded another increase for this next week. I seem to be eating to much and too late in the evening. This seems to have a connection between with not the best night sleep. Is there a rule of when the last food in the evening should be?

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    Hi KCF,

    Thanks for the question – I think this is one that is probably relevant for lots of people.

    Getting stuck in this kind of cycle can be very difficult. Anxiety can be quite crafty and so we can sometimes get caught off guard, as you describe. Despite this, most of us reading this will probably be nodding our heads and being all too familiar with this cycle ourselves! The fact is that you've described it really well there KCF. You've noticed that it often happens with a particular set of triggers (e.g. important days etc.) and that acknowledgement of this often leads to the anxiety inducing cognition (“I've got to get to sleep” ... i.e. if I don't get to sleep I won't manage etc.) which then leads to an anxiety response (I'm guessing: increased respiratory rate and pulse, tense shoulders, whirring mind, difficulty concentrating etc.) in response to the threat of difficulty the next day. These anxiety symptoms don't allow us to fall asleep (we have evolved such that anxiety stops us falling asleep in the presence of danger – quite helpful when there is a physical threat but not so helpful when the threat is one that we hold in our mind).

    The key to the above, therefore, is beginning to see the pattern day to day and to acknowledge it when it's happening. Often we “miss” the initial thought and get caught up in the aftermath of the anxiety. Just because we miss the initial thought, however, doesn't mean it's a write-off. We can still use relaxation techniques such as those in the programme (e.g. progressive muscle relaxation) to help the anxiety dissipate. The key, as I say, is acknowledging when we've got caught in one of these cycles and looking to change our standard response (it might be as simple as saying to yourself “Ah I seem to be caught in one of those cycles again – it's crept up on me again … etc.). For most people, the standard response is to try and think themselves out of the problem or somehow try and sidestep it or ignore it. The trouble is that this often makes the anxiety worse because we re-trigger it again and again. Instead, acknowledging the cycle and seeing it for what it is (a short-term threat-based response to a potential difficult day) and looking for a way to consciously step out of the cycle is probably the best way to manage it. Once you've acknowledged where you are, perhaps give yourself a conscious choice – to either do the standard response or to opt out and do some active relaxation instead. The relaxation isn't with the intention of falling asleep, it's simply a means of helping to dissipate the anxiety. One technique that people often tell me they find helpful is a mindful body scan, a mindfulness technique. With all the attention being placed on tuning in to the feelings in the various parts of the body in turn, one's attentions are no longer on the anxiety thoughts or on the desire to fall asleep.

    Hope that helps! There's more on dealing with anxious thoughts as you move through the programme too.

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    Hi Cfack,

    Thanks for the question. I'm sorry to hear that you've struggled to get restorative sleep. This is something lots of people who struggle to sleep describe and it can be very debilitating. Hopefully this is something that will improve as you continue the course and work through the programme. It's tricky to offer any more advice without knowing a bit more about your situation.

    I just wanted to pick up on the stats too – I hope you won't mind and I don't mean to be pedantic! I'm not sure where you got the data on your sleep stages from but if it was from a wearable device I'd take that with a pinch of salt. In order for us (in clinic or in the lab) to determine how much time people spend in a particular sleep stage (e.g. REM sleep, NREM Stage 2 [“lighter sleep”] or NREM Stage 3 [“deeper sleep”]) we have people do an overnight polysomnography study. The patient is hooked up to electrodes that measure neural activity and sensors that measure heart rate, eye movement, respiratory rate and muscle movement. This information is then all interpreted by a highly trained sleep technician. I haven't seen any evidence that wearable devices can provide this kind of information and I get worried about the way in which people might be being misled. In my sleep clinic, I often see people who access that kind of information on a wearable device and then get worried about the readouts. In fact, my colleagues and I conducted an experimental study on this area last year and found that people with insomnia experience worse daytime symptoms when they are told that their sleep on the preceding night was poor. Those who are told they had good sleep don't show any change in their symptoms. I'm certainly not being critical of your interest in your sleep data (I'm very interested in sleep data myself!) but I just wanted to offer a friendly caution about the unestablished validity of wearable devices as regards this kind of information.

    Keep up the great work with the programme and let us know how you get on as you go.

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    Hi Js,

    A great question and not an uncommon concern for many people.

    I suppose the first thing to say is that you're being completely reasonable! Who would want to get out of bed where it's warm and go and wait around for a while before they fall asleep? The thing is, there is good reason to do it and it's an important part of the programme. I'm going to assume that you are clear on the rationale for doing the 15-minute rule and so I'll refer you back to the video from the Prof if you want to refresh your understanding.

    Often one thing I recommend to people I see in clinic who struggle with this is for them to rehearse what they are going to do well in advance of nighttime. People sometimes put their fluffiest dressing gown on their bed so that it's ready for them when they need to get out of bed, others might put a blanket on the sofa so that they can snuggle up there and read. The important thing then is to have a clear idea of what it is that you're going to do for that period of time (e.g. reading a good book or doing a relaxation exercise). If you have a plan, you're much more likely to follow it than if you don't. The other thing that might be helpful to do is to talk yourself through the rationale for the rule in the first place. Remind yourself that staying in bed won't help you get to sleep any quicker, it might even push sleep further away. It's also probably not going to help long-term. However, although it's difficult, this extra effort now will.

    It's not easy but once again it's part of the behavioural treatments (stimulus control and sleep restriction) that we know from numerous robust and well controlled clinical trials that show great improvements.

    Keep up the great work and bon courage!

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    Hi Auntie Hoho,

    Certainly – great question. Sleep-wake regulation is done through two processes: 1) the homeostatic sleep drive (the way we get more and more sleepy the longer we stay awake e.g. from 7am we gradually get more tired until 11pm at night, for instance) and 2) our circadian rhythm.

    We have evolved to specialise as daytime animals and so we naturally sleep at night and are awake and active during the day. The circadian rhythm is entrained daily by several timers that are known in German as zeitgebers (“time givers”). The most powerful of these time givers is light – which when it hits the photoreceptive retinal ganglion cells at the back of the eyeball lets the biological clock (the suprachiasmatic nucleus) know that it's time to be awake. The SCN then sets the clocks for all the little clocks that the rest of the body's cells have. This light suppresses the release of a natural sleep hormone called melatonin that is secreted by the pineal gland each evening shortly before our natural sleep time when we are in dim light (this is known as dim light melatonin onset). Bright light in the eye before bed will suppress the secretion of melatonin and thereby “push” the clock forward meaning that we don't sleep until later.

    Bright light in the morning is a bit like the little chap who climbs Big Ben (the big clock in London) and sets it to the right time each day (I'm not sure if there actually is such a man but it illustrates the point!). Natural light (i.e. bright light from the sun) is the kind of light that we have evolved to set our clock by and it is the most effective way to set the clock. Light is quantified by a value called lux and bright natural sunlight on a clear summer day might be anything up to 120,000 lux (approximately!) whereas light from a light bulb might be nearer 80 lux. Light boxes that people use for SAD or for Bright Light Therapy are usually around 10,000 lux. Getting out and about and exposed to natural sunlight therefore helps entrain the body clock is a great way to keep the circadian rhythm in time. We can, of course, exposure ourselves to sun by sitting next to a window, being outside, driving in the sunshine etc.

    Hope this helps.

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    Hi Sleepyjomo,

    I'm sorry to have taken so long to get round to answering your question, thanks for asking it.

    I'm sorry to hear that you've found things so difficult. I think that you'll certainly get lots of people agreeing with you that Sleep Restriction can be really tricky and, as I've said earlier, is the part of the treatment which most people find challenging. I think the substantive and important point here is that if you're struggling to manage the anxiety because of the sleep restriction, then perhaps it is best that you follow the rest of the programme but leave the sleep restriction for now. This doesn't mean you won't find some benefit to the programme in other areas and it certainly doesn't mean that you won't be able to come back to it when you're ready (and if you choose to!).

    Incidentally, the clinical guidance for managing insomnia in the context of mental health difficulties is that both are given the space for treatment separately (i.e. we don't just bung it all together or see them as mere symptoms of one another). In that sense, it sounds really sensible to be tackling the anxiety concertedly with your therapist and perhaps this is where you need to place your focus for now. You can certainly continue with the programme and use the other elements of the treatment to maintain the treatment of the insomnia.

    I hope this helps clarify and keep up the great work.

  • Sleepio Member

    • 129 comments
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    in reply to Sleepio Member
    Expert

    Hi Featherly,

    Congratulations on the progress – well done!

    There's no hard and fast rules about eating but my experience clinically is that people often report doing better when they eat earlier rather than later. This is, by and large, going to be an individual choice and isn't going to be something we all agree on. Why not experiment with different times and go with what works best for you?

  • Sleepio Member

    • 129 comments
    • 46 helped
    Expert

    Well, that's all we have time for this evening folks.

    Thanks for the great questions and keep up the great work everyone!

    We'll be back again next week for another Live Discussion.

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